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11/1/2010
1
EXPANDING ACCESS TO
SPECIALIZED HEALTH CARE
FOR POOR AND EXCLUDED
POPULATIONS IN THE
ANCASH REGION – PERU
Authors:
Inga Salazar, Richard
Nino Guerrero, Alfonso
Vigo Obando, Ina
CONTENTS
I. General Information
II. Problem
III. Objectives
IV. Scope of Intervention
V. Methods
VI. Results
VII.Conclusions
I. GENERAL INFORMATION
� Peru: Total population28,220,764 inhabitants
� Urban population75.9 %
� Poverty rate:2005:54.%2010: 39.3%
� Mortality rate per 1000 live births: 6
I. GENERAL INFORMATION
Peruvian Health System Information
� 73% of the population seeks medical attention in publicservices provided by the Ministry of Health, which are not fr ee.The rest of the population seeks attention in: Social Securi ty:17.9%, Armed Forces: 3%, Private: 5.9%.
� In 2001 the Peruvian government created Public Insurance,called the “Integral Health Insurance” (SIS) to provide fre ehealthcare for the extremely poor and excluded population.
� Currently SIS coverage reaches 18.5% at a national level.
� Health establishments: First level centers: 8,486Hospitals: 469
94%
6%
POPULATION OF THE PROJECT : 427,141 PEOPLE.
No reciben atención especializada
NEED SPECIALIZED CARE: 86,429
� In the Ancash Region, thepoor and excludedpopulation:
� 86,429 people requirespecialized healthcare
� Only 6% receive it
� Excluded and Disperse Population: area with the greatest population dispersement at aregional level, located more than four (4) hours on a track and by river, or the means oftransport most frequently used by the healthcare center. R.M. 478-2009/MINSA.Technical Regulation for Integral Healthcare for Excluded and DispersePopulations.
II. THE PROBLEM: INEQUITY AND
EXCLUSION
Not received
specialized
care
5,186 people receive
specialized care
II. PROBLEM: INEQUITY AND EXCLUSION
BARRIERS ACTIONS CARRIED OUT BY THE GOVERMENT
LIMITATIONS
ECONOMIC Integral Health Insurence(SIS) for the poor and excluded population.
Benefits plan includes little specializedhealthcare.
GEOGRAPHIC Basic attention brigades for excluded and disperse populations (AISPED)
Insufficient regarding numbers.
FUNCTIONAL The offer is insufficient andconcentrated in the big cities.
Specialized doctors in Ancash: 0.13surgeons per 10,000 residents, 0.4pediatricians per 10,000 children.
CULTURAL Vertical births, waiting homes for pregnant women
Partially implemented.
11/1/2010
2
III. OBJECTIVE
Expand access to specialized healthcare for thepoor and excluded population through thedevelopment of new mobile healthcarestrategies, linking the attention levels andinvolving local actors in the Ancash Region,Peru.
IV. SCOPE OF INTERVENTION
� 407 Km. Northeast of Lima
� 427,141 (37% of regional total: 1’154,523 residents)
� 390 disperse and excluded communities
� 44 first level centers
� 10 hospitals
ANCASH REGION
V. METHODS
Component 1: Development of a mobile specialized healthcare model.
Selection of cases on the
first level
Specialized healthcare
campaigns in local hospitals
Specialized healthcare
campaigns in schools
1.1 1.2 1.3
COMPONENT 1
1.11.11.11.1
C C C
cc
c
Educational
Institutions
Specialized healthcare campaignsin local hospitals
AISPED: Basic Attentionand selection of cases that need
specialized healthcare
Specialized
healthcare
campaigns in
schools
Referrals to level II hospitals, National Hospitals and Institutes via SIS
EE.SS.
First level
Selection of Cases that need specialized
healthcare
1.31.31.31.3
1.21.21.21.2
� Training for the selection of cases based on prevalent pathologies by specialty to personnel from the AISPED brigades and first level centers.
� Standardization of instruments by specialty for the selection of cases.
� Improvement of the brigades’ equipment for the selection of cases: Snellen card, occlusometer, speculum, glucotest, PRAT equipment.
SELECTION OF CASES ON THE FIRST LEVEL1.11.11.11.1
Ophthamology Gynecology Internal Medicine Surgery
SPECIALIZED HEALTHCARE CAMPAIGNS
IN LOCAL HOSPITALSB
E
F
O
R
E
D
U
R
I
N
G
A
F
T
E
R
Analysis of the volume
and type demanded in
order to program
specialties
Adaption of the
installations and
processes
Coordination with
the main hospital
and local actors
Admission and
registration of
patients, based
on programming
External
consultation,
diagnostic aid
exams, medicine
Monitoring the
perceived quality,
satisfaction
surveys
Surgery: RxQx,Informed consent,
security checklist, hospitalization
Clinical Records
Archive in the
Main Hospital
Referrals via
Public Insurance
(SIS)
Report to
Regional Health
Board
Post op follow up
and delivery of
glasses
1.21.21.21.2
11/1/2010
3
� Odontology: Classrooms free from active cavities
� Ophtamology and delivery of glasses.
� Pediatric care
SPECIALIZED HEALTHCARE IN EDUCATIONAL
INSTITUTIONS1.31.31.31.3
Strengthening skills for
specialized healthcare
Improving the quality of
healthcare in hospitals
Strengthening the reference and
counter-reference system
V. METHODS
Component 2 : Strengthening the public healthcare sector for specialized healthcare in order to genera te sustainability.
2.1 2.2 2.3
STRENGTHENING SKILLS FOR SPECIALIZED
HEALTHCARE
280 healthcare workers involved in specialized healthcare, trained inservice
35 training odontologists to manage PRAT (Atraumatic RestorationPractice) and in surgical techniques
65 updating doctors in level I hospitals in managing transmitablediseases, chronic illness and diagnostics through images.
30 Masters in Hospital Management15 Masters in Medical Audit
2.12.12.12.1
IMPROVING QUALITY OF HEALTHCARE IN
HOSPITALS
Standardization of healthcare processes for external consultationsand surgery: clinical history by specialty, pre-op evaluation andsurgical risks, informed consents, surgical safety checklist in 100%of the patients attended.
Implementation of medical audit system in hospitals and auto-evaluation of quality standards.
Satisfaction surveys carried out by external users to evaluatequality. 84% of the attended users satisfied with the attentionreceived.
Improved use of information (indicators)
2.22.22.22.2STRENGTHENING OF REFERENCE AND
COUNTER-REFERENCE SYSTEM
Implementation of 45 first level centers with radiocommunication equipments.
Tele-medicine pilot: tele-electrocardiography and tele-spirometry in level I hospitals, placing priority on the mostdistance areas.
2.32.32.32.3
11/1/2010
4
INDICADOR DE PROPOSITO
73%
27%
POPULATION OF THE PROJECT : 427,141 PEOPLE..
No reciben atención especializada
Reciben algun tipo de atención especializada
Need Attention: 86,429
23,383 people receive
specialized care
VI. RESULTS
The population receiving specialized healthcare increased from 6% to 27%.
Not received specialty
care
Receives some kind of
specialized care
Q 128.54%
Q 255.64%
Q 315.77%
Q 40.04%
Q 50.01%
Chart 1: Consultations by poverty quintilePAAES. march to november 2008
8.75
%
5.26
%
4.89
%
4.66
%
4.35
%
4.03
%
3.54
%
2.22
%
1.94
%
1.90
%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
CA
RIE
S D
E L
A
DE
NT
INA
GA
ST
RIT
IS Y
D
UO
DE
NIT
IS
VU
LV
OV
AG
INIT
IS
DE
FE
CT
O
RE
FR
AC
TIV
O
PR
ES
BIC
IE
INF
EC
CIO
N
TR
AC
TO
UR
INA
RIO
PA
RA
SIT
OS
IS
INT
ES
TIN
AL
PT
ER
IGIO
N
MIO
PIA
AM
ET
RO
PIA
Chart 4: Ten leading causes of general morbidityPAAES: March - November 2008
%
ACUM
Internal medicine25.1%
Ophthalmology
22.0%
Pediatrics11.2%
Gynecology12.3%
Surgery2.7%
Other specialties
1.9%
Dentistry24.9%
Chart 2: Consultations by type of specialtyPAAES, march to November 2008
14.9% 11.7%
54.8%
18.6%
20.5
%
20.7
%
48.2
%
10.4
%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Childrens Teens Adults Seniors
Chart 3: Attended by age groupPAAES March a November. 2008
% ATD
% de pob 2008
CONCLUSIONES
� It is feasible to reduce barriers to access andto bring specialized attention to the poor anddisperse population by applying strategiesrelated to a mobile healthcare, linkingattention levels and involving local actors.
� Providing specialized healthcare applyingmobile strategies to disperse and excludedpopulations is more efficent than implementinga fixed offer.
VII. CONCLUSIONSVII. CONCLUSIONSVII. CONCLUSIONSVII. CONCLUSIONS CONCLUSIONES
� The applied methodology could beused by the current Public Insurance(SIS) in order to expand access todisperse populations.
� The project has contributed toimproving the quality of life of theattended population by reducingincapacity and mortality related topathologies that demand specializedhealthcare.
VII.CONCLUSIONS
Thanks for your attention